Festoons are folds of skin and muscle that look like a drape that is hung from one corner of the eye to the other with the lowest part of the sagging skin directly below the pupil. There can be a single festoon or there can be multiple festoons under one eye or both eyes. Because festoons are made from folds of the lower eyelid muscle (oribicularis oculi muscle), they improve and flatten out when the patient squints and tightens the muscle.
As we age the lower eyelid skin becomes very thin and stretched out. When the lower eyelid skin gets stretched out, it sags under the eye like a drape. The thin sagging lower eyelid skin hits the thicker cheek skin below it and gets bunched up. Festoons are made worse by the age-related loss of bone and fat below the muscle of the lower eyelid. This combination of bone and fat loss deep to the lower eyelid, causes the lower eyelid skin and muscle to become wrinkled like a deflated balloon.
The term “festoons” is commonly miss used, even by professionals, to describe other age-related changes of the lower eyelid region. Festoons are different from malar bags or malar mounds . Malar bags are mounds of smooth skin that are below the lateral corners of the eye. Malar bags do not have wrinkles over them, but they do have a sharp crease at the bottom of them. Malar bags do not get better when you squint and contract your lower eyelid muscles. Festoons are also different from the “bags” under ones’ eyes. Bulges immediately below the eyelashes of the lower eyelid are caused by collections fat deep to the lower eyelid muscle. This is called pseudo-herniation of orbital fat.
Treatment of Festoons
When patients with festoons have very thin and very stretched out lower eyelid skin, it is often best to start with trying to tighten and improve the skin quality. The simplest and easiest way to do this is to start an at home skin regimen. This skin regimen consists of applying topical retinoids (retin-a or retinol) and mild acids to the thin wrinkled skin of the lower eyelid.
A stronger treatment, consist of a chemical peel or series of chemical peels to the lower eyelid skin of the festoons. You may not be a candidate for a strong chemical peel if your skin is dark. Currently available laser treatments that claim to tighten the skin without any down time, in my opinion, are not cost-effective treatments. You spend a lot of money and time for very little, if any, improvement. Older lasers, such as a CO2 laser do work, but they have a long down time and higher risks of scarring and pigmentation issues. Therefore, I rarely use these older, stronger lasers on lower eyelid skin. This skin is just too sensitive and delicate.
The last treatment option for significant amounts of excess skin associated with festoons is surgical excision of the folds. There are two different ways of improving festoons with surgery. One way of surgically improving festoons is to perform a lower eyelid blepharoplasty using a skin-muscle flap. In this procedure an incision is made in a wrinkle below the eyelashes. The incision is brought down through the lower eyelid skin and muscle and then the skin and muscle are re-positioned superiorly, thus smoothing out the festoon. The excess skin and muscle are then excised.
Another surgical procedure is called a lower blepharoplasty using a “skin pinch”. In this procedure the festoon itself is excised and the skin is sewn together. In both procedures, there is a fine scar that is hidden in naturally occurring wrinkles. Both surgical procedures can be done under local anesthetic.
Festoons can be made worse when there is a significant amount of bone loss and/or fat loss from the area under the eyes. In youth the skin and muscle are distributed over the full convexity of the cheek. As we get older and the supporting structures involute, the skin and muscle bunch up like a deflated balloon. In these situations, injectable filler is placed in the cheek and below the eyelid muscle (orbicularis oculi muscle). The filler replaces the lost support structure of the lower eyelid muscle and skin, and therefore smooths out the festoons.
Often times, patients need a combination of these treatments to get the best results.